U.S. Sen. Grassley
Senator eyes Miami doctor
Sen. Charles Grassley pointed to a Miami doctor in an attempt to show that the government needs to do something about over-utilization of healthcare.
By John Dorschner
A Miami psychiatrist who writes prescriptions for Medicaid patients at a rate of 150 a day, seven days a week, has been targeted by a U.S. senator as an example of why the federal government should do more to investigate over-utilization of healthcare.
The biting letter, from Sen. Charles Grassley, R-Iowa, to federal Medicaid officials comes at a time when authorities are looking for ways to reduce what experts believe is massive overspending in areas like Miami, where healthcare costs can be more than twice the national average, as healthcare reform advocates look for ways to find the money to spread coverage to the uninsured.
The Grassley letter does not mention Fernando Mendez-Villamil by name, but noted ``with alarm'' documents from the Florida Agency for Healthcare Administration about a single prescriber who wrote 96,685 prescriptions from the last half of 2007 through the first quarter of 2009 for Medicaid patients.
AHCA records independently obtained by The Miami Herald show that the doctor is Mendez-Villamil, who wrote nearly twice as many prescriptions for mental health drugs as the No. 2 Medicaid prescriber in the state.
The huge number ``means that this physician wrote approximately 153 prescriptions each and every day, assuming he did not take vacations,'' Grassley wrote.
Mendez-Villamil told The Herald he works long hours and sees patients only for 10 minutes every two or three months. Medicaid pays him $45 per office visit. Each patient may require four or five prescriptions, he said, accounting for the large numbers he writes.
``When you know the patient, and the patient is stable, 10 minutes is long enough,'' said Mendez-Villamil, whose office is on Coral Way. He said he sometimes works 12-hour days during the week as well as Saturday mornings. He said he only prescribes what's medically necessary.
A reporter visiting his office at 8 a.m. on Saturdays has found a couple of dozen patients milling around out front, waiting to get in to see him.
Mendez-Villamil, 42, received his medical degree from the Universidad Central del Caribe in Puerto Rico. He did his residency in psychiatry at Jackson Memorial Hospital and has been licensed in the state since 1998.
The mental health drugs that Mendez-Villamil prescribes do not generally have a value as street drugs but they are expensive. He writes thousands of prescriptions a year for Zyprexa ($841.93 for 30-day supply at Drugstore.com), Abilify ($634) and Seroquel ($430). All Medicaid drugs are paid for by Florida taxpayers.
David Katz, a Yale doctor specializing in public health issues, said it's tough to critique a doctor's work from afar, but he and others have abiding concerns about mental health treatment for underserved populations, such as poor Medicaid patients. Low reimbursement rates can lead to the ``knee-jerk use of prescription medications,'' which can ``translate into substandard care and preventable harm.''
Alfred Jonas, a Miami psychiatrist who's been practicing for more than a quarter-century, said he wondered about Mendez-Villamil's practice. ``There are psychiatric patients who can be seen every two months because they are so stable,'' Jonas said, ``but it's inconceivable to me that one's entire caseload would be like that, especially if they require four or five medications.
``And if they require that many prescriptions, it's unlikely that many wouldn't also need psychotherapy,'' which requires far more than a 10-minute session. ``It's all way too much for coincidence.''
In his letter to Kathleen Sebelius, secretary of Health and Human Services, Grassley demanded to know ``what systems'' federal agencies ``have in place to monitor utilization rates across the country?''
In an e-mail to The Herald Thursday afternoon, AHCA Press Secretary Tiffany Vause wrote that the state has a contract with the University of South Florida to monitor prescribing practices of doctors who write behavioral health prescriptions.
``The number of prescriptions recorded for Dr. Fernando Mendez-Villamil is high when compared to other Medicaid prescribers,'' Vause wrote, but the number does not ``indicate that there is anything improper regarding his prescribing. If a doctor is a specialist like Dr. Fernando Mendez-Villamil. . . it can be expected that he would have a high number of clients requiring the specialized treatment offered by psychiatric medications.''
Vause wrote many of the prescriptions the psychiatrist wrote could have been for refills. She said AHCA uses a warning system of ``edits'' that indicate causes for concern about a doctor's prescribing patterns. ``Mendez-Villamil has a small percentage of prescriptions that hit against these edits.''
Drug makers recommend that doctors monitor closely patients taking atypical antipsychotics, because users are prone to obesity and diabetes. In 2007, Mendez-Villamil prescribed this class of drugs 6,000 times, state records show. He told The Herald that he leaves possible side effects, such as diabetes, to the patients' general practitioners.